From Total War to the birth of the NHS

Seventy-five years ago this week, on 8 May 1945, the world was celebrating the end of war in Europe. Six years of ‘total war’ had forced the pace of change in many areas of politics, medicine, technology and society, none more so than in the development of public health and, with it, the ambulance service.

Prior to the outbreak of World War II ambulance services - like all medical services - were organised locally with councils, metropolitan boards and hospitals managing their own vehicles. Voluntary organisations, such as the Red Cross and St John, also operated ambulances at home and abroad. However these services weren’t co-ordinated and offered vastly different ways of working and levels of care. In some areas, an ambulance trip would even cost you a fee!

As war loomed, eyes turned to how Britain would cope with the expected numbers of civilian casualties on the Home Front. Up to that point there had been very little appetite for wholesale changes to the way medical services were run but the government recognised that a more organised, joined-up approach was needed to meet the demand a conflict would cause. So it was that, in 1939, the Emergency Hospital Service (EHS) was created specifically to deal with casualties caused by enemy bombing.

Although it may not have been obvious at the time, this was a pivotal moment in the history of public health in the UK. It not only marked the first time that healthcare funding and provision had been taken over by central government; because the EHS (sometimes also referred to as the Emergency Medical Service) guaranteed free treatment to every casualty it dealt with, it was also the first time that the government had offered free medical help to all patients irrespective of income or ability to pay.

The EHS employed medical staff to care for those injured by enemy action and provide treatment as required. Under the scheme hospitals managed themselves as they had in peacetime but the Ministry of Health dictated the type of work they did, and paid for their services accordingly. By the outbreak of war more than 2,300 hospitals had been brought under the auspices of the Government.

As some of these hospitals were in the countryside, the legislation included the provision of an organised ambulance service to move patients to and between hospitals. Working together as the Joint War Organisation, the Red Cross and St John Ambulance (through its Transport of Wounded department) supported the EHS and in 1942 the scheme was expanded to include civil defence, bringing in services provided by Air Raid Precautions workers. More recruits came through the launch of the London Auxiliary Ambulance Service, which recruited around 10,000 members, many of them women.

The pressures of war meant that finding ambulances - and the people to drive them - was often difficult. Many different vehicles were pressed into service during WWII because of demand and during the Blitz the need for ambulances was so great that vans, coaches and buses were often commandeered. One respondent to the BBC’s People’s War project remembers driving a van that had belonged to a Liverpool department store, Lewis’s, before it was repurposed as an ambulance.

Despite the struggles, the success of the EHS had provided an example of what could be achieved by a co-ordinated, national medical service bringing separate and competing institutions together. Adding extra impetus to the idea of a centralised health service was the famous Beveridge Report, published in 1942, which stated that healthcare was crucial to slaying the ‘five giants on the road to reconstruction’; want, disease, squalor, ignorance and idleness. By the time the country took to the streets to celebrate VE Day in May 1945, the foundations of the National Health Service had already been laid.

In 1948 the NHS was launched, promising care ‘from cradle to grave’. This extended to ambulance units; the new legislation required local authorities to provide them, free of charge, to all those who needed them.

The ambulance service that emerged immediately after World War II was still a long way from the professional service we know today. In the early days of the NHS ambulances were still largely managed at a local level and continued to rely heavily on volunteers. Professionalisation began in earnest in the 1960s, when crews had to have some first aid training and began to treat patients, rather than simply transport them to hospital. In 1974 ambulance services were finally brought under the control of their local NHS area and only in 2001 did it become illegal to use the title ‘paramedic’ unless fully trained and registered with the Health Professions Council.

It is an irony that out of the chaos and crisis of a war that took millions of lives grew our National Health Service; a beloved institution that has saved millions more and continues to do so every day.